<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01//EN">
<html>
  <head>
    <title></title>
  </head>
  <body>
    <form name="creditCardForm" method="post" action="#" id="creditCardForm">
      <input type="hidden" name="CCForm.addNewCO" value="true">
      <table>
        <col width="135">
        <col width="550">
        <tr valign="top">
          <td>
            <img src="#" width="125" height="80" alt="">
            <table>
              <col width="65">
              <col width="60">
              <tr>
                <td>
                  <img src="#" width="60" height="38" alt="">
                </td>
                <td>
                  <img src="#" width="60" height="38" alt="">
                </td>
              </tr>
              <tr>
                <td colspan="2" height="5"></td>
              </tr>
              <tr>
                <td>
                  <img src="#" width="60" height="38" alt="">
                </td>
                <td>
                  <img src="#" width="60" height="38" alt="">
                </td>
              </tr>
            </table>
          </td>
          <td>
            <!-- begin billingPageCreditCards -->
            <div class="BodyXLBold">
              Pay With a Credit Card or Debit Card
            </div>
            <div class="BodyM">
              Make the most of your shopping experience with the Walmart Discover® or Walmart Credit Card®. <a href="javascript:triggerChildOmniture('Pay%20with%20a%20Credit%20Card%20or%20Debit%20Card','Learn%20More');%20popupHelp('/cservice/contextual_help_popup.gsp?modId=447772',%20'',%20600,%20350);">Learn More</a> or <a href="/instantcredit/StartApplicationFromBilling.do">Apply Now</a>.<br>
              Debit cards (also called check cards, ATM cards or bank cards) are accepted if they have a Visa or MasterCard logo.
            </div><!-- end billingPageCreditCards -->
            <table>
              <col width="135">
              <col width="415">
              <tr>
                <td class="BodyMBold">
                  Type of Card
                </td>
                <td class="BodyM">
                  <select name="CCForm.cardType">
                    <option value="">
                      Enter a new card
                    </option>
                    <option value="Wal-Mart Credit Card">
                      Wal-Mart Credit Card
                    </option>
                    <option value="Wal-Mart Discover">
                      Wal-Mart Discover
                    </option>
                    <option value="DISCOVER">
                      DISCOVER
                    </option>
                    <option value="VISA">
                      VISA
                    </option>
                    <option value="MASTERCARD">
                      MASTERCARD
                    </option>
                    <option value="AMEX">
                      AMEX
                    </option>
                  </select>
                </td>
              </tr>
              <tr>
                <td colspan="2" height="10"></td>
              </tr><!-- CC Number -->
              <tr>
                <td class="BodyMBold">
                  Card number
                </td>
                <td class="BodyM">
                  <input type="text" name="CCForm.cardNumber" maxlength="125" size="16" value="">
                </td>
              </tr>
              <tr>
                <td colspan="2" height="10"></td>
              </tr><!-- Expiration Date -->
              <tr>
                <td class="BodyMBold">
                  Expiration date
                </td>
                <td>
                  <select name="CCForm.expirationMonth">
                    <option value="1">
                      1
                    </option>
                    <option value="2">
                      2
                    </option>
                    <option value="3">
                      3
                    </option>
                    <option value="4">
                      4
                    </option>
                    <option value="5">
                      5
                    </option>
                    <option value="6">
                      6
                    </option>
                    <option value="7">
                      7
                    </option>
                    <option value="8">
                      8
                    </option>
                    <option value="9" selected="selected">
                      9
                    </option>
                    <option value="10">
                      10
                    </option>
                    <option value="11">
                      11
                    </option>
                    <option value="12">
                      12
                    </option>
                  </select> <select name="CCForm.expirationYear">
                    <option value="2011" selected="selected">
                      2011
                    </option>
                    <option value="2012">
                      2012
                    </option>
                    <option value="2013">
                      2013
                    </option>
                    <option value="2014">
                      2014
                    </option>
                    <option value="2015">
                      2015
                    </option>
                    <option value="2016">
                      2016
                    </option>
                    <option value="2017">
                      2017
                    </option>
                    <option value="2018">
                      2018
                    </option>
                    <option value="2019">
                      2019
                    </option>
                    <option value="2020">
                      2020
                    </option>
                    <option value="2021">
                      2021
                    </option>
                    <option value="2022">
                      2022
                    </option>
                  </select>
                </td>
              </tr>
              <tr>
                <td></td>
                <td class="BodyM">
                  Not required for Walmart Credit Card
                </td>
              </tr>
              <tr>
                <td colspan="2" height="10"></td>
              </tr>
              <tr>
                <td class="BodyMBold">
                  Name as it appears on card
                </td>
                <td class="BodyM">
                  <input type="text" name="CCForm.name" size="20" value="">
                </td>
              </tr>
              <tr>
                <td colspan="2" height="10"></td>
              </tr><!-- CID Editor -->
              <tr valign="top">
                <td class="BodyMBold">
                  Card Identification Number
                </td>
                <td class="BodyM">
                  <table>
                    <tr valign="top">
                      <td>
                        <input type="text" name="CCForm.cid" size="5" value="">
                      </td>
                      <td>
                        <img src="#" width="36" height="24" alt="">
                      </td>
                      <td>
                        <div class="BodyMBold">
                          Visa, MasterCard, Discover, Walmart Cards:
                        </div>
                        <div class="BodyM">
                          Last 3 digits on back of card.
                        </div>
                      </td>
                    </tr>
                    <tr>
                      <td colspan="3" height="5"></td>
                    </tr>
                    <tr valign="top">
                      <td></td>
                      <td>
                        <img src="#" width="36" height="24" alt="">
                      </td>
                      <td>
                        <div class="BodyMBold">
                          <span class="CheckoutBodyTextAccent">American Express:</span>
                        </div>
                        <div class="BodyM">
                          <span class="CheckoutBodyTextAccent">Last 4 digits in small print on front of card.</span>
                        </div>
                      </td>
                    </tr>
                    <tr>
                      <td></td>
                      <td colspan="2" class="BodyM">
                        <a href="#" onclick="triggerChildOmniture('Card Identification Number','Need Help?'); window.open('/cservice/cid_help_popup.gsp','cidhelp','width=550,height=650')">Need help?</a>
                      </td>
                    </tr>
                  </table>
                </td>
              </tr>
            </table>
            <h4>
              Billing Address
            </h4>
            <p class="BodyM">
              This address must match your credit card's billing address.
            </p>
            <div>
              <input id="checkForBillingAddress" name="isBillingAddress" type="checkbox" onclick="javascript:clickBillCheckbox()"> <span class="BodyM">Same as Shipping address</span>
            </div>
            <table>
              <col width="135">
              <col width="415"><!-- Company Name -->
              <tr>
                <td class="BodyM">
                  Company Name
                </td>
                <td>
                  <input type="text" name="CCForm.companyName" maxlength="40" size="30" value=""> <span>(optional)</span>
                </td>
              </tr>
              <tr>
                <td colspan="2" height="7"></td>
              </tr>
              <tr>
                <td colspan="2">
                  <!-- begin ccAddressFields -->
                  <table>
                    <col width="135">
                    <col width="260"><!-- STREET 1 -->
                    <tr>
                      <td class="BodyMBold">
                        Address Line 1
                      </td>
                      <td>
                        <input type="text" name="addressForm.street1" maxlength="125" size="30">
                      </td>
                    </tr>
                    <tr>
                      <td colspan="2" height="7"></td>
                    </tr><!-- STREET2 -->
                    <tr>
                      <td class="BodyM">
                        Address Line 2
                      </td>
                      <td>
                        <input type="text" name="addressForm.street2" maxlength="125" size="30"> <span>(optional)</span>
                      </td>
                    </tr>
                    <tr>
                      <td colspan="2" height="7"></td>
                    </tr><!-- CITY -->
                    <tr>
                      <td class="BodyMBold">
                        City
                      </td>
                      <td>
                        <input type="text" name="addressForm.city" maxlength="125" size="30">
                      </td>
                    </tr>
                    <tr>
                      <td colspan="2" height="7"></td>
                    </tr><!-- STATE -->
                    <tr>
                      <td class="BodyMBold">
                        State
                      </td>
                      <td>
                        <select name="addressForm.state">
                          <option value="">
                            Choose State
                          </option>
                          <option value="AL">
                            Alabama
                          </option>
                          <option value="AK">
                            Alaska
                          </option>
                          <option value="AZ">
                            Arizona
                          </option>
                          <option value="AR">
                            Arkansas
                          </option>
                          <option value="CA">
                            California
                          </option>
                          <option value="CO">
                            Colorado
                          </option>
                          <option value="CT">
                            Connecticut
                          </option>
                          <option value="DE">
                            Delaware
                          </option>
                          <option value="DC">
                            District Of Columbia
                          </option>
                          <option value="FL">
                            Florida
                          </option>
                          <option value="GA">
                            Georgia
                          </option>
                          <option value="HI">
                            Hawaii
                          </option>
                          <option value="ID">
                            Idaho
                          </option>
                          <option value="IL">
                            Illinois
                          </option>
                          <option value="IN">
                            Indiana
                          </option>
                          <option value="IA">
                            Iowa
                          </option>
                          <option value="KS">
                            Kansas
                          </option>
                          <option value="KY">
                            Kentucky
                          </option>
                          <option value="LA">
                            Louisiana
                          </option>
                          <option value="ME">
                            Maine
                          </option>
                          <option value="MD">
                            Maryland
                          </option>
                          <option value="MA">
                            Massachusetts
                          </option>
                          <option value="MI">
                            Michigan
                          </option>
                          <option value="MN">
                            Minnesota
                          </option>
                          <option value="MS">
                            Mississippi
                          </option>
                          <option value="MO">
                            Missouri
                          </option>
                          <option value="MT">
                            Montana
                          </option>
                          <option value="NE">
                            Nebraska
                          </option>
                          <option value="NV">
                            Nevada
                          </option>
                          <option value="NH">
                            New Hampshire
                          </option>
                          <option value="NJ">
                            New Jersey
                          </option>
                          <option value="NM">
                            New Mexico
                          </option>
                          <option value="NY">
                            New York
                          </option>
                          <option value="NC">
                            North Carolina
                          </option>
                          <option value="ND">
                            North Dakota
                          </option>
                          <option value="OH">
                            Ohio
                          </option>
                          <option value="OK">
                            Oklahoma
                          </option>
                          <option value="OR">
                            Oregon
                          </option>
                          <option value="PA">
                            Pennsylvania
                          </option>
                          <option value="RI">
                            Rhode Island
                          </option>
                          <option value="SC">
                            South Carolina
                          </option>
                          <option value="SD">
                            South Dakota
                          </option>
                          <option value="TN">
                            Tennessee
                          </option>
                          <option value="TX">
                            Texas
                          </option>
                          <option value="UT">
                            Utah
                          </option>
                          <option value="VT">
                            Vermont
                          </option>
                          <option value="VA">
                            Virginia
                          </option>
                          <option value="WA">
                            Washington
                          </option>
                          <option value="WV">
                            West Virginia
                          </option>
                          <option value="WI">
                            Wisconsin
                          </option>
                          <option value="WY">
                            Wyoming
                          </option>
                          <option value="AA">
                            Armed Forces Americas
                          </option>
                          <option value="AP">
                            Armed Forces Pacific
                          </option>
                          <option value="AE">
                            Armed Forces other
                          </option>
                          <option value="AS">
                            American Samoa
                          </option>
                          <option value="GU">
                            Guam
                          </option>
                          <option value="MP">
                            Northern Mariana Islands
                          </option>
                          <option value="PW">
                            Palau
                          </option>
                          <option value="PR">
                            Puerto Rico
                          </option>
                          <option value="VI">
                            Virgin Islands
                          </option>
                        </select>
                      </td>
                    </tr>
                    <tr>
                      <td colspan="2" height="7"></td>
                    </tr><!-- ZIP -->
                    <tr>
                      <td class="BodyMBold">
                        Zip Code
                      </td>
                      <td>
                        <input type="text" name="addressForm.zip" maxlength="20" size="10">
                      </td>
                    </tr>
                    <tr>
                      <td colspan="2" height="7"></td>
                    </tr><!-- PHONE -->
                    <tr>
                      <td class="BodyMBold">
                        Phone Number
                      </td>
                      <td>
                        <input type="text" name="addressForm.phone" maxlength="20" size="25"> <span class="BodyM">(Must be the number associated with your credit card)</span>
                      </td>
                    </tr>
                  </table><!-- end ccAddressFields -->
                </td>
              </tr>
              <tr>
                <td colspan="2" height="10"></td>
              </tr>
              <tr>
                <td></td>
                <td>
                  <input type="image" src="#" width="86" height="25" alt="Continue">
                </td>
              </tr>
            </table>
          </td>
        </tr>
      </table>
    </form>
  </body>
</html>
